The foundations of medicine are changing beneath our feet, and for those least sure of their footing, it can be an unsettling place to stand. The recent COVID pandemic has undoubtedly exacerbated this changing landscape. For senior medical students entering practice, there is some concern over the impact the pandemic may have had on their preparation due to limited clinical exposure. Certainly, these incoming and future interns will need engaged, timely and comprehensive support like never before.
In 1967 the American Academy of Pediatrics (AAP) introduced the Medical Home concept to help coordinate the care of children with chronic health conditions. The Medical Home model, as defined by the Patient-Centered Primary Care Collaborative (PCPCC), is “a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.” Compassionate, and culturally effective care were added later.
Medical Homes recognize the need to improve access and care for a vulnerable population, but do our trainees constitute such a population? We know that some will go on to experience chronic health-deteriorating stress, burnout, and a variety of mental health concerns. In addition, they routinely face obstacles accessing behavioral health services, primary medical or dental care, and other wellness-enhancing services.
Administrative burden, proficiency with the electronic health records, and other responsibilities vie for the limited time and energy trainees need to learn the essential knowledge and skills of their specialty. Using this framework, our sponsoring institution moved from a GME-embedded wellness program required by the ACGME Common Program Requirements (Section VI) to a more comprehensive Medical Home for Wellbeing. To our knowledge, ours is the first institution to adapt this module to a wellness program.
Wellness Program Characteristics
A successful well-being program requires individual “Wellbeing Champions” to lead the effort and an advisory committee to inform and support those efforts. These Wellness Champions must have excellent leadership skills, expertise in quality improvement and physician wellbeing, determination, and leadership support (i.e., training, protected time, budget) to be successful for such a formidable task.
Our resident Wellness Committee operates within our Office of Graduate Medical Education (OGME), develops, and helps operationalize the committee’s agenda, and has representation from across specialties with engaged faculty and resident participation. In addition, we have a robust Behavioral Health Program (BHP) to support the residents, fellows, and faculty.
Our team, like many, includes dedicated Psychologists, Psychiatrists, an Employee Assistance Program, and cognitive screening services. Together they support the longitudinal screening, counseling, coaching, and case management needs of residents and fellows. We use the Interactive Screening Program from the American Foundation for Suicide Prevention for trainees, but have also expanded screening, brief anonymous counseling, and referral resources to faculty. While not a crisis service, our providers routinely assist in triaging these trainees to ensure their safe referral.
The Elevated Wellness Home
Our Wellness Home includes faculty development of Wellness Champions, a proactive behavioral health program, student to resident transition screening, faculty development of wellness committee members is a critical component in our Wellness Home model. Developing committee members into more knowledgeable and engaged Wellness Champions, helps advance the committee’s agenda inside their home departments.
Our committee meetings routinely include literature reviews, guest speakers, and robust dialogue about topical events impacting our organization and how best to address them. Past meetings have included discussions on racial unrest, COVID-related moral injury, coaching for women in academic medicine and resident isolation.
The OGME Wellness Committee serves also as a centralized hub for review and distribution of wellness literature to our programs, while also creating, vetting and operationalizing specific institutional goals. Workshops, lectures, and grand rounds on well-being topics are offered continuously to departments and community organizations on request.
In the Wellness Home model our BHPs proactively offer services to residents directly within their departments. Brief 15–20-minute voluntary “check-in” visits called “Domain Pulse Checks” allow trainees to examine personal domains of function, i.e., social, emotional, financial, etc., while being provided with resources and support. Since no counseling is performed, a more formal BHP visit can be arranged if needed.
Often overlooked, spouses of residents and fellows are assisted through a quarterly Spousal Support program. Our Wellness Home approach recognizes the need to introduce resident screening early, before July 1, during new-resident orientation. We designed the Transition to Residency Risk Index (TRRI) to identify individuals at moderate or high risk for a difficult transition to residency, and then assists programs in building a support network for them over the first several months of residency. Those at highest risk are offered resources within their programs and support by our BHPs.
Another source of actionable wellbeing data comes from the ACGME Faculty and Resident Survey. This annual survey includes local, specialty, and national normative wellness data for both faculty and residents. This program level data is compared against the national specialty means as well as that program’s previous performance on the same wellness metrics.
Ensuring Access to Primary Care and Other Support Services
As previously stated, physicians are notoriously poor at taking care of their own health. The Wellness Home works through the institutional clinical departments and your University Hospital partners to provide trainees with more immediate “one-call” access to primary care visits aligned with their complex schedules.
With an increasingly female physician workforce, we work to reduce barriers to well-women, gynecologic and obstetrical visits, while expanding access to nearby, fully equipped lactation rooms. Our School of Dentistry provides similar one-call access for semi-urgent and urgent dental matters. The OGME, Wellness Home and sponsoring institution worked together to get residents access to Care.com for vetted childcare, pet-care, elder care, and other healthcare options.
Special Programs (Struggling Learner, Worst-Case Events, Compassion Course)
On occasion residents may struggle in their residency programs, which if not addressed early may lead to adverse actions. Our Struggling Learner Program seeks to intervene when a resident has seemingly exhausted their resources within their training program; offering a safety net to explore these cases with fresh eyes. Issues of organizational skills, toxic work environments, incivility, Title IX complaints, and microaggressions are a few of the topics identified and addressed. The success of these programs is well documented.
It is also important to prepare for the sudden death of a resident by illness, trauma or death by suicide. Worst-Case Event protocols were created to immediately address the consequences of these events in a thoughtful but expedited manner, limiting misinformation and contagion. Institutional drills help assure that the protocol and resources function in the manner intended. Finally, a Wellness Home must continue to innovate new approaches to impact the culture of wellness in the institution. Recently, our program developed a longitudinal Compassion Course for residents modeled upon the Compassion-Integrity Program at Life University.
Even before the Covid-19 pandemic, residency training was challenging. Yet as we emerge from the pandemic and return to more normalcy, rates of chronic stress, burnout, and other mental health concerns have never been higher. Physician wellness now as always represents an urgent priority for all national medical organizations, and efforts are underway to move the focus primarily from the individual to workplace culture and systems of care.
During this process, our trainees and their faculty must continue to remain adaptive to change while building their intrinsic resilience. The Wellness Home model appears well positioned to drive change within the learning environment, while providing the many layers of support and accessibility necessary to optimize resident and fellow performance in a respectful and compassionate environment.